Med/Surg I, Module 4 Part 1 of 4

1. Med/Surg I, Module 4Part 1 of 4 Orthopedic System Alteration in Mobility Integumentary System

2. Chronic Musculoskeletal Conditions • Curvature of the Spine • Osteoporosis • Osteomyelitis • Osteoarthritis

3. Curvature of the Spine Kyphosis (left) and Lordosis (right) Kyphosis Source: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center. http://medicine.ucsd.edu/clinicalimg/thorax-kyphosis.html Lordosis Source: Image courtesy of Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Center. http://medicine.ucsd.edu/clinicalimg/thorax-kyphosis.html

4. Scoliosis Source: Wikimedia Commons, Public Domain http://commons.wikimedia.org/wiki/Category:Orthosis

5. Osteoporosis Increased Risk • Family history • Female • Menopause-related low estrogen females, low testosterone males • Medications • Lifestyle

6. Osteoporosis Prevention • Diet • Calcium supplements • Stop smoking • Alcohol and caffeine intake • weight-bearing exercise • Sunlight

7. Osteoporosis Diagnosis • Dual-energy x-ray absorptiometry (DEXA) scan • Qualitative ultrasound (QUS) of heel or calcaneus

8. Osteoporosis Collaborative Management • Replace estrogen or testosterone • Raloxifene (Evista) • Biphosphonates: Alendronate (Fosamax) and risedronate (Actonel) • Teriparatide (Forteo) • Ibandronate sodium (Boniva) • Calcitonin (Miacalcin) • Sodium fluoride

9. Osteoporosis Nursing Care • Prevent falls • Treat pain • Orthotic devices • Refer to physical therapy • Range of motion exercises

10. Osteomyelitis • Local swelling • Redness • Tenderness • Pain • Fever • Bone pain Source: UCSD Catalog of Clinical Images,Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California, 92093-0611 http://medicine.ucsd.edu/clinicalimg/extremities-Toe-Osteo.html http://medicine.ucsd.edu/clinicalimg/extremities-osteomyelitis.html

11. Diagnosis • Bone scan • Biopsy • MRI, CT or ultrasound: fluid collection, abscess, periosteal thickening • Elevated WBC, positive blood cultures

12. Collaborative Care • Surgical debridement is the primary treatment • Postoperative care: wound irrigation with strict sterile technique; monitor site for signs of infection, monitor temperature and WBC • Most cases caused by Staphylococcus aureus: • Parenteral antibiotics based on wound, blood cultures for 4-6 weeks or • Oral twice-daily ciprofloxacin if chronic • Hyperbaric oxygen therapy to promote healing

13. Osteoarthritis Reprinted with permission: Charles J. Eaton, M.D. of The Hand Center http://www.eatonhand.com/ Reprinted with permission: DePuy Orthopaedics, Inc. http://www.depuyorthopaedics.com/

14. Clinical Manifestations • Crepitus • Joint stiffness • Pain with movement • Heberden’s nodes (distal joints) and Bouchard’s nodes (proximal joints) • Knees: Joint effusions • Muscle atrophy • Spine: radiating pain, stiffness, muscle spasms in extremities • Hips: pain referred to inguinal area, buttock, thigh or knee; loss of internal rotation

15. Collaborative Care • Analgesics • Rest • Heat • Weight control • TENS

16. Total Joint Arthroplasty Source: Hughston Foundation http://www.hughston.com/hha/a.11.2.1.htm Source: Hughston Foundation http://www.hughston.com/hha/a.11.2.1.htm

17. Postoperative Care • Abduction pillow, neutral position • Prevent embolus • Prevent infection • Assess for bleeding • Neurovascular compromise • Manage pain • Promote activity

18. Total Knee Arthroplasty • Continuous passive motion (CPM) device • Ice or hot/ice machine • Keep knee in neutral, no rotation inward or outward • Monitor: thromboembolism, infection, bleeding, CSM • Teach: no hyperflexion or kneeling for 6 weeks

19. Acute Musculoskeletal conditions: FRACTURES Source: Wikimedia Commons/Creative Commons Licence Phote courtesy of “Mexican 2000”/Flickr http://commons.wikimedia.org/wiki/Image:Clavicle_fracture.jpg

20. Open or Closed? Photo source: American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=A00139

21. Compound Fractures • Grade I • Small wound • Grade II • ~1 cm to 10 cm • skin & muscle contusions • Grade III • Large • Damaged skin, muscle, nerves, vessels

22. Assessment • Can he move it? • Does it hurt? • Is it deformed?

23. Key Treatments • Closed reduction • Immobilization • Splint • Cast • Open reduction Open reduction; External Fixation National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center http://jama.ama-assn.org/cgi/reprint/291/17/2160.pdf

24. Cast Care • Prevent indentations when wet • Elevate uniformly • Air dry • CSM – What am I looking for? • No scratching implements!

25. Skin Traction • To decrease muscle spasm • Weight 5-7 pounds attached w/ adhesive tape • Used before surgical repair • Check sling, tape for placement • Keep pulley, weights in place Photo Source: www.HealCentral.org, Royal College of Surgeons of Ireland (RCSI), Creative Commons

26. Buck’s Traction • Hip fracture assessment • What to do immediately? • Buck’s traction assessments • What should be done later? • What teaching is needed? Buck’s Traction Source: DeRoyal Patient Care http://www.deroyal.com/PDFCatalogs/orthopedicCatalog.aspx

27. Other Skin Traction • Russell’s • Cervical • Thomas splint • Bryant’s • Cervical • Pelvic

28. Skeletal Traction • Weight 25-40 pounds • Are the ropes on the pulleys? • Are the weights hanging free? • Where are the knots? • Monitor CSM • Pin care? • Skin care

29. Balanced Suspension • Counter-traction by weights • Check ropes, knots, weights • Are traction bars tightened? • Is patient in alignment? • How do pin sites look? • When can I remove weights?

30. Spinal Traction • Where are the knots? • Are the weights hanging free? • What do the pin sites look like? • How do I turn the patient? • How can I make the patient comfortable?

31. Complications • Compartment syndrome • Fat embolism • DVT • Osteomyelitis • Aseptic necrosis

32. Compartment Syndrome • Prevention • Check CSM • Ice, elevate • Loosen dressing, open cast • Emergency care • Fasciotomy:

33. Fat Embolism • Long bones, multiple fractures • Elderly: hip fractures • Altered mental status • Respiratory distress • Petechiae on trunk • Prevention: early immobilization of fracture

34. Deep Venous Thrombosis • Most common complication • Predisposing factors • Common sites: leg, pelvic fx • Pulmonary embolus prevention Deep Vein Thrombosis Source: National Heart & Blood Institute http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt/DVT_WhatIs.html

35. Osteomyelitis • Sources: open wounds, implanted hardware • Staphylococcus aureus usually • Rx: IV antibiotics

36. Aseptic Necrosis • Death of bone tissue • Hip fractures or bone displacement • Hardware interferes with circulation

37. Amputation • Diabetic, smoker, infected foot ulcer • Trauma • Grieving loss • Altered self concept • Coping • Family response

38. Surgical WoundsWeb Resource • http://alfa.saddleback.edu • Click tab titled, “Med-Surg 1” • Drop down menu  choose “Wound Care”

39. Wound Assessment Measure the wound in centimeters Assess phase of wound healing • Reaction • Regeneration • Remodeling Wound location, color of wound bed, condition of wound margins, integrity of surrounding skin Signs and symptoms of infection Drainage: amount, color, consistency, odor

40. Wound Care Dressing • The ideal dressing • Keeps wound moist • Prevents maceration • Protects from contamination • Contains wound fluid • Protects granulation tissue

41. Traditional dry dressings • Wounds exposed to air are more inflamed, painful, itchy and have thicker crusts than moist wounds • Epithelium migrates into wound bed: if must burrow between any eschar (crust or Wet to dry dressing significantly increase healing time • Nonocclusive: increased risk of contamination and infection

42. Moist Wound Healing • No eschar develops (crust, scab) • Enhances autolytic debridement: promotes role of macrophages and leukocytes • Bacterial barriers: prevent wound contamination • Wound fluids kept at site: contain growth factors and enzymes that promote autolysis and healing

43. Potential for Infection Signs of infection • I-induration • F-fever • E-erythema • E-edema

44. Absorptive powders and pastes • Used in heavily draining wounds: absorb up to 100x weight in fluid: may increase wound pH above physiological levels • May require wrapping in gauze before inserting into wound bed Pastes easier to remove from wound

45. Wound Healing Normal healing (3R's) • Reaction: inflammatory process (72 hours) • Regeneration: proliferation (up to three weeks) • Remodeling: (three weeks to two years)

46. Black Wound = Eschar Cellular debris will escape wound edges as necrotic tissue begins to separate from granulation tissue If eschar becomes contaminated: • becomes excellent medium for infection • wound remains in reaction or inflammatory stage • systemic signs of infection Eschar delays regeneration phase by interfering with cell migration and wound closure Risk of wound infection increases as the amount of necrotic tissue increases Needs debridement

47. Yellow Wound Tissue not damaged enough to form an eschar so wound covered with thick yellow fibrous debris or viscous exudate • High risk of infection due to excellent medium for bacterial growth • Needs continuing debridement Photo courtesy of Saddleback College, California, http://www.saddleback.edu/alfa/N170/woundclassification.aspx

48. Red Wound • Red indicates presence of granulation tissue. • Color of granulation tissue affected by nutritional status and blood supply • full thickness ulcer: crater with pale pink to beefy red granulation tissue • crater slowly fills with granulation tissue from bottom upward • Wound contraction and epithelialization continues. Epithelialization occurs from wound edges inward.

49. Wound Drainage Devices • Decrease pressure in the wound by removing excess exudate thereby promoting healing from the inside (secondary healing). • Examples: Penrose drain, Jackson-Pratt & Hemovac suction devices

50. Dehiscence/Evisceration Partial or complete separation of the outer wound layers. If the internal organs below the wound protrude out of it, the wound has eviscerated. Highest risk is in obese patients, diabetics or those receiving steroids.